Embed Size (px)
Citation preview
Page 1 of 4
Risk Assessm
ent Form
11/16
Mental Health Transport Risk Assessment Form This form is intended to be used by services in order to identify the following: Section 1: Assessed by Section 2: Personal Particulars Section 3: Risk Assessment Matrix Section 4: Result of Assessment
THIS FORM IS USED TO ASSESS RISK ASSOCIATED WITH MENTAL HEALTH TRANSPORTATION ONLY AND SHOULD NOT REPLACE INDIVIDUAL AGENCY OPERATIONAL OR CLINICAL PROTOCOLS.
The purpose of information sharing is to ensure each agency has sufficient information to enable them to provide effective and appropriate services. Collection and disclosure should be limited to personal information that is necessary and relevant to these purposes and occur in accordance with Section 576 and 577 of the Mental Health Act 2014.
SECTION 1 – Assessed by
Medical or Authorised Practitioner: __________________________________________________ Centre / Clinic / Hospital: ___________________________________________________________ Treated On: ______/_______/_______
SECTION 2 – Personal Particulars
Surname: __________________________ Given Names: _____________________________________Date of Birth: _______/_______/_______ Language Spoken:_________________________________ Address: _____________________________________________________________________________ Add the patient’s current residential address in this field. If the patient is located at another place, record the address and location in the notes field supplied in Section 4.
Is the patient currently receiving treatment for a mental illness? Yes ⃝ No ⃝
SECTION 3 – Risk Assessment Matrix
Complete Attachment A • Indicate risk for each criterion by placing a tick in the applicable box. • Each matrix is a tool to record information and provide guidance on a suitable transport option. If the majority of boxes ticked align to one risk category, the clinician’s informed judgement should be used to determine if this is the most appropriate risk rating and transport option. • Reasons for not selecting the risk rating that aligns to the majority of boxes ticked should be recorded in the Risk Rating Rationale section on the following page.
SECTION 4 – Result of Assessment
Form 4A ‐ Transport Order: Completed ⃝ Transport Type: Inter‐Hospital ⃝ Community to Hospital ⃝
Transport by: Mental Health Transport Officer ⃝ Police Officer ⃝ (Metropolitan area only)
NEXT STEPS 1. Identify bed availability (contact local inpatient service Bed Manager or delegate) 2. Book transport with appropriate provider (or refer to WA Police where appropriate) 3. Provide appropriate documentation to transport providers and others involved
Referrer’s Name:_______________________________ Contact Number:________________________Please inform receiving site when the patient departs pick up location. This will ensure necessary resources can be in place to support the patient admission.
SM
HM
R99
0 M
enta
l Hea
lth
Tra
nsp
ort
Ris
k A
sses
smen
t
Page 2 of 4
Risk Assessm
ent Form
11/16
RISK ASSESSMENT NOTES This section has been provided to record notes relevant to the risk assessment. Details such as next of kin/trusted friend, location of crisis, patient’s behaviour and/or demeanour, current or history of mental illness/treatment, severity of situation and agency response can be recorded here. MEDICAL OR AUTHORISED PRACTITIONERS REQUESTING THE TRANSPORT ARE REQUIRED TO RECORD A COMPREHENSIVE RISK ASSESSMENT (INCLUDING APPROPRIATE DETAIL). ALL STAFF INVOLVED IN TRANSPORTATION ARE REQUIRED TO UTILISE UNIVERSAL PRECAUTIONS TO MITIGATE THE RISK OF INFECTIOUS DISEASES.
Risk Rating Rationale:
Delusional systems that may impact on safe escort (e.g. fear of authority figures):
Access to weapons, concealed or otherwise:
Sensory impairment (e.g. sight, hearing, intoxication):
Medical considerations that may impact on safe escort (e.g. heart condition, epilepsy):
Has the patient’s Family/Carer been notified regarding the transfer? Yes ⃝ No ⃝ Family/Carer Contact Name: ___________________________ Number:________________________ Does the patient have children that need care? Yes ⃝ No ⃝ (please specify arrangements made)
Notes:
Name: ____________________ Signature: _________________ Designation: ___________________
Date: _______/_______/_______ Time: _____________________
Men
tal H
ealt
h T
ran
spo
rt R
isk
Ass
essm
ent
SM
HM
R99
0
Page 3 of 4
Risk Assessm
ent Form
11/16
PATIENT TRANSPORT PROVIDER USE ONLY (IF REQUIRED)
Notes/Comments:
Is the Patient Transport Provider unable to transport the patient? ⃝ Reason why the Patient Transport Provider is unable to transport the patient (mandatory):
*Please note: If the Patient Transport Provider is unable to transport the patient, the practitioner or psychiatrist making the 4A – Transport Order will need to determine the most appropriate course of action. Name: ______________________ Signature: ___________________
Date: _______/_______/_______ Time: _____________________
SM
HM
R99
0 M
enta
l Hea
lth
Tra
nsp
ort
Ris
k A
sses
smen
t
Page 4 of 4
Risk Assessm
ent Form
11/16
Attachment A - Mental Health Patient Transport Matrix
Please note: ‐ St John Ambulance is a contracted Patient Transport Provider for the metro and Bunbury area only. St John Ambulance provides general patient transport throughout the State; however, this may be via
a volunteer service in non‐metropolitan areas, and WA Police assistance may be required. ‐ Royal Flying Doctor Service transfers may include reference to this matrix for the purposes of Police involvement in the flight; however, aeromedical transports have additional criteria for assessing
Police involvement in air transport.
